Provider Demographics
NPI:1417057779
Name:JONES, KELLY N (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:JONES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776084
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6084
Mailing Address - Country:US
Mailing Address - Phone:636-893-1356
Mailing Address - Fax:636-893-1358
Practice Address - Street 1:15945 CLAYTON RD STE 310
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2493
Practice Address - Country:US
Practice Address - Phone:636-893-1356
Practice Address - Fax:636-893-1358
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-116148207Q00000X
IL036116148207QB0002X
MO2024038766207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116148Medicaid
ILP00369032OtherRAILROAD MEDICARE
IL08232205OtherBLUE CROSS BLUE SHIELD
IL036116148Medicaid
ILP00369032OtherRAILROAD MEDICARE